Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 53 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
3J
0K
0L
Actual harm
9G
0H
0I
Potential for more than minimal harm
27D
10E
4F
Potential for minimal harm
0A
0B
0C
July 22, 2026Complaint inspection · 2 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staff to ensure residents receive showers and assistance with care. These failures have the potential to affect all 97 residents living in the facility.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to maintain the highest practicable physical and psychosocial well-being for 3 of 3 residents (R1, R2, and R3) reviewed for quality of care in the sample of 4.
January 20, 2026Complaint inspection · 1 citation
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review the facility failed to identify severe weight loss of three residents and failed to provide needed interventions to prevent further weight loss for 3 of 3 residents (R1, R3 and R7) reviewed for weight loss in a sample of 7. This failure resulted in R1, R3 and R7 experiencing severe weight loss.
January 8, 2026Complaint inspection · 2 citations
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to provide the identified level of supervision and assistance required to prevent PICA behaviors for one of three residents (R4) reviewed for supervision in the sample of 11.
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on interview and record review, the facility failed to provide person-centered interdisciplinary behavioral health services and appropriate supervision to 1 of 3 residents (R4) reviewed for behavioral health services in the sample of 11.
December 3, 2025Complaint inspection · 1 citation
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sink located in the kitchenette of the resident's dining room was maintained and in good repair. This has the ability to affect all 98 residents residing in the facility. Findings Include:On 12/2/2025 at 11:22 AM, the sink area of the kitchenette was observed to have a copious amount of black substance to the bottom shelf and to both sides of the sink cabinet wall, with multiple dead gnats on the bottom drawer face. The bottom shelf was also noted to be broken. Black substance was also sporadically noted in areas around the ceiling vent located above the refrigerator in this same area. On 12/2/2025 at 11:23 AM, V8 (Maintenance Director) stated he had been notified by the kitchen staff about 2-3 weeks ago regarding the sink area located in the kitchenette. [...]
October 22, 2025Complaint inspection · 1 citation
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review the facility failed to safely transfer a resident with a mechanical lifting device for 1 of 3 (R1) residents reviewed for accidents in a sample of 3. This failure resulted in R1 sustaining an impacted fracture of the right humeral neck. This past noncompliance occurred from 10/10/25 to 10/16/25.
July 16, 2025Complaint inspection · 2 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. This failure resulted in R1 stabbing R2 in the back multiple times with an ink pen and both R1 and R2 being sent to the emergency room for evaluations. This past noncompliance occurred between 7/11/25 and 7/12/25.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview, observation, and record review, the facility failed to investigate a bruise of unknown origin as potential physical abuse for 1 of 4 residents (R1) reviewed for abuse in the sample of 4. R1's Face Sheet documented an admission Date of 5/30/24 and listed diagnoses including Unspecified Dementia, Major Depressive Disorder, and Anxiety Disorder. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Inventory for Mental Status (BIMS) Score of 8, indicating R1 has moderate deficits in cognition. R1's Care Plan dated 6/9/25 documented a problem area, (R1) has been the recipient and aggressor of verbal and physical aggression related to dementia, and continual reorganization of personal belongings and environment. R2's Face Sheet documented an admission Date of 6/26/24 and documented diagnoses including Epilepsy and Cerebral Palsy. [...]
June 12, 2025Standard inspection · 2 citations
- F
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview, observation, and record review the facility failed to dispose of expired medications. This has the potential to affect all 91 residents living in the facility.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview the facility failed to ensure proper hand hygiene was performed before assisting dependent residents with eating and while serving residents glasses for 4 of 8 residents (R10, R58, R72, and R88) observed for dining in a sample of 51.
January 17, 2025Complaint inspection · 1 citation
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe transfers with mechanical lifts, implement interventions for falls, and follow facility policy to complete assessments and investigations post resident fall for 4 (R1, R2, R3, and R6) of 6 residents reviewed for accidents int the sample of 6.
August 29, 2024Standard inspection, Complaint inspection · 21 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote3. R259s Face sheet documents an admission date of 07/30/24, with diagnoses of unspecified dementia severe with agitation, altered mental status, anxiety disorder, unspecified osteoarthritis, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, acute cystitis with hematuria and atherosclerotic heart disease of native coronary artery without angina pectoris. R259's Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 00, which indicates severely impaired cognition. This MDS also documented R259 was dependent with eating, oral hygiene, toileting, and dependent with transfers. Under Fall History, R259's MDS documented on Admission/Entry or Reentry: R529 has had a fall within the last month. R259's Care plan, dated 07/31/24, documents a focus area of, '(R259) is at risk for falls related to: [...]
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from verbal/mental and physical abuse for 1 of 2 (R45) residents reviewed for abuse in the sample of 51. This failure would cause a reasonable person to experience feelings of fear, anxiety, and insecurity while living in their home. Findings Include: R45's admission Record, with a print date of 8/20/24, documents R45 was admitted to the facility on [DATE], with diagnoses that include diabetes, dysphagia, osteoarthritis, brief psychotic disorder, delusional disorder, mild cognitive impairment, and depression. R45's MDS (Minimum Data Set), dated 8/20/24, documents R45 has a BIMS (Brief Interview for Mental Status) score of 10, which indicates a moderate cognitive impairment. [...]
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide medications and treatments as ordered by a physician, failed to document reassessments, and evaluate residents for advanced treatment needs for 3 (R63, R68, R100 ) of 3 residents reviewed for quality of care in a sample of 51. This failure resulted in R63 missing medication for approximately 30 days, suffering shortness of breath, and being admitted to the hospital for three days.
- G
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional supplements, monitor weights, and implement interventions for 2 (R53 and R100) of 8 residents reviewed for nutrition in a sample of 51. This failure resulted in R53, who only weighed 76 pounds and had a recent 23% weight loss in 6 months, not receiving the ordered nutritional supplements to be able to maintain a healthy weight.
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing in adequate numbers to meet the needs of the residents. This failure has the potential to affect all 99 residents who currently reside at the facility. Findings Include: The facility untitled resident roster, dated 8/11/24, documents 99 residents currently reside at the facility. 1. R21's Face sheet, dated 08/22/24, documents an admission date of 03/30/3023 with diagnoses of unspecified dementia, type 2 diabetes mellitus, hypothyroidism, depression, anxiety, history of falling, weakness, muscle wasting, and atrophy. R21's Minimum Data Set (MDS), dated [DATE], documents in Section C a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderately impaired cognition. Section GG documents partial/moderate assistance with toileting and transfers. [...]
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to promote dignity for while eating, recieving care, and waiting for care for 4 of 6 residents (R30, R53, R68, R259) reviewed for dignity in a sample of 51.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide support for residents who require assistance completing Activities of Daily Living, including personal hygiene and eating assistance for 7 out of 11 residents (R2, R16, R30, R49, R63, R68, R74) reviewed for Activities of Daily Living assistance in the sample of 51.
- E
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/implement individualized, person-centered interventions to attain the highest practicable physical, mental, and psychosocial well-being for 5 of 7 residents (R15, R25, R49, R74, R96) reviewed for dementia care treatment and services in a sample of 51.
- E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide all items noted on the daily menu and ensure availability of substitutions for 4 (R73, R43, R31 and R7) of 4 residents reviewed for menus meeting resident choices in a sample of 51 .
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights were protected when they failed to ensure Advanced Directives were obtained and/or documented for 2 of 2 (R157 and R161) residents reviewed for advance directives in the sample of 51. Findings Include: 1. R157's admission Record, with a print date of [DATE], documents R157 was admitted to the facility on [DATE] with diagnoses that include gangrene, cellulitis, diabetes, peripheral vascular disease, atrial fibrillation, and edema. R157's undated current Care Plan does not document a Focus Area related to Advanced Directives or R157's end of life wishes. R157's medical record did not document a POLST (Physician's Orders for Life-Sustaining Treatment) form. [...]
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review, the facility failed to provide notification of a room change for one (R63) of one resident reviewed for notification of room change in a sample of 51.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed report a bruise of unknown origin to the Administrator for one (R49) of two residents reviewed for abuse in a sample of 51.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to investigate a bruise of unknown origin and failed to provide assessments on this resident for 1 of 2 residents (R49) reviewed for abuse in the sample of 51.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review, the facility failed to complete and provide bed hold documentation for one (R63) of one resident reviewed for bed hold documentation in a sample of 51.
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview and record review, the facility failed to do a PASARR II (Preadmission Screening and Resident Review) for 2 of 4 residents (R15 and R49) reviewed for screenings in a sample of 51.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure newly identified pressure areas were assessed including measurements and descriptions of the area, and interventions were implemented for 1 (R27) of 7 residents reviewed for pressure ulcers in the sample of 51. Findings Include: R27's admission Record documents R27 was admitted to the facility on [DATE], with diagnoses that include diabetes, hypertension, chronic kidney disease, muscle wasting, and cognitive communication deficit. R27's Minimum Data Set (MDS), dated [DATE], documents R27 has a Brief Interview for Mental Status (BIMS) score of 12, which indicates a moderate cognitive deficit. This same MDS documents R27 requires partial to moderate assist for bed mobility and transfers, is at risk of developing pressure ulcers, and has a pressure reducing device for his chair and bed. [...]
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to ensure narcotics were available and administered as ordered to prevent pain for 1(R157) of 2 residents reviewed for pain in the sample of 51. Findings Include: 1. R157's admission Record, with a print date of 8/16/24, documents R157 was admitted to the facility on [DATE], with diagnoses that include gangrene, cellulitis, diabetes, peripheral vascular disease, atrial fibrillation, and edema. R157's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 14, which indicates R157 is cognitively intact. R157's current Care Plan documents the following Focus area of, Has .pain related to: Osteoarthritis, Peripheral vascular disease, Wounds. Date Initiated 7/29/24 The interventions for this Focus area initiated 7/29/24 are, Administer analgesia as per orders . [...]
- D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/revise and implement interventions to ensure preventative measures were consistently implemented for pica (ingesting non-food items) behavior for 1 (R45) of 1 resident reviewed for behavioral health services in the sample of 51. Findings Include: R45's admission Record, with a print date of 8/20/24, documents R45 was admitted to the facility on [DATE], with diagnoses that include diabetes, dysphagia, osteoarthritis, brief psychotic disorder, delusional disorder, mild cognitive impairment, and depression. R45's MDS (Minimum Data Set), dated 8/20/24, documents R45 has a Brief Interview for Mental Status (BIMS) score of 10, which indicates a moderate cognitive impairment. [...]
- D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on record review and interview, the facility failed to ensure the attending physician documented a specific diagnosis in the medical record for the use of a psychotropic medication for 1 of 5 residents (R96) reviewed for unnecessary medications in the sample of 51.
- D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids as ordered by the physician for 1 (R86) of 9 residents reviewed for diets prepared meet individual resident needs in the sample of 51. Findings Include: R86's admission Record, with a print date of 8/16/24, documents R86 was admitted to the facility on [DATE], with diagnoses that include other symptoms and signs concerning food and fluid intake, and chronic respiratory failure with hypoxia. R86's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 05, indicating R86 has a severe cognitive deficit. This same MDS documents R86 requires a Mechanically altered diet-require change in texture of food or liquids (e.g., pureed food, thickened liquids). [...]
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide diets as ordered for 2 (R67 and R73) of 14 residents reviewed for therapeutic diets in a sample of 51.
July 24, 2024Complaint inspection · 4 citations
- J
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteFailures at this level require more than one Deficient Practice Statement. A. Based on observation, interview, and record review, the facility failed to ensure a resident was free from neglect when they failed to accurately assess, treat, and prevent a significant decline in condition for 1 (R1) of 3 residents reviewed for neglect in the sample of 24. This failure resulted in R1, who has a history of confusion with infections, experiencing altered mental status and refusing overall care after being diagnosed with a urinary tract infection. R1's refusals of care additionally led to R1 developing a Stage 3 pressure ulcer, an unstageable pressure ulcer with sepsis secondary to skin and soft tissue infection, subsequently requiring an 11-day hospitalization for IV antibiotic therapy. [...]
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents assessed as being at risk for elopement were supervised, interventions to prevent elopement were implemented, and incidents of elopement were thoroughly investigated for 1 of 3 (R16) residents reviewed for accidents and supervision in the sample of 24. This failure resulted in R16, who had a history of elopement and was assessed as being at risk of elopement, exiting the facility and walking approximately two tenths of a mile down a busy road without staff supervision. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 6/13/24 when R16 was identified to be at risk for elopement and the facility did not implement interventions to prevent elopements. [...]
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review the facility failed to identify, treat, and prevent the development of pressure ulcers for 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 24. This failure resulted in R1 developing a Stage 3 wound and an Unstageable wound to bilateral buttocks.
- E
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate allegations of witnessed peer to peer abuse when they failed to substantiate that abuse occurred, and failed to investigate one allegation of abuse for 4 of 7 (R6, R7, R8, R9) residents reviewed for abuse in the sample of 24. Findings Include: The facility policy Abuse Prevention Program (dated 10/2022) documents, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: .establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; [...]
June 28, 2024Complaint inspection · 2 citations
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to prevent an accident for 1 (R2) of 3 residents reviewed for accidents in the sample of 9. This failure resulted in R2 receiving a 2 cm (centieter) laceration to the right side of the forehead and being sent to the emergency room requiring 2 sutures. Findings Include: R2's admission Record documents R2 was admitted to the facility on [DATE], and is [AGE] years old. R2's admission Record documents diagnoses including but not limited to Diagnoses: [...]
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation and interview, the facility failed to provide mouthcare for 1 (R9) of 3 residents reviewed for ADL's (Activities of Daily Living) in the sample of 9.
May 22, 2024Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure thorough assessments for changes in condition were provided and documented (R1 and R8), and failed to identify, assess and treat wounds (R1) for 2 of 3 residents reviewed for quality of care in a sample of 21. These failures resulted in both R1 and R8 experiencing discomfort due to a delay in treatment. R1 experienced prolonged respiratory distress resulting in R1's transport to the local hospital, and R8 required transport to the local hospital with subsequent hospital stay for altered mental status, Urinary Tract Infection with hematuria, and acute pulmonary edema. Findings Include: 1. [...]
April 4, 2024Complaint inspection · 4 citations
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from misappropriation of medications for 3 of 3 residents (R1, R2, and R3) reviewed for misappropriation of property in the sample of 7. Findings Include: 1. R1's face sheet documented an admission date to the facility on [DATE], with diagnoses including: Type 2 Diabetes Mellitus with Diabetic Nephropathy, Osteoarthritis, Morbid Obesity, Chronic Gout, and Low Back Pain. R1's cumulative Physician Order Summary documents a 9/13/20 order for oxycodone-Acetaminophen 10-325 milligrams, take 1 tablet by mouth 4 times a day for pain. R1's Minimum Data Set (MDS), dated [DATE] Section C0500, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. 2. R2's face sheet documented an admission date of 03/14/2023, with diagnoses including: [...]
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement the facility's abuse policy for 3 of 3 residents (R1, R2, and R3) reviewed for misappropriation of property in a sample of 7.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to operationalize its Abuse Policy by notifying local law enforcement when a reasonable suspicion of a crime has been committed in the facility for 3 of 3 residents (R1, R2, and R3) reviewed for abuse in the sample of 7.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to maintain accurate records of narcotics and administer medications to meet the needs of the residents for 3 of 3 residents (R1, R2, and R3) reviewed for pharmacy services in a sample of 7.
September 14, 2023Complaint inspection · 1 citation
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on interview, observation and record review, the facility failed to provide an operational call light system for 2 of the 5 residents (R7, R8) reviewed for call lights in the sample of 5.
May 18, 2023Standard inspection · 8 citations
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff to provide care to the residents residing at the facility. This has the potential to affect all 99 residents residing at the facility. Findings Include: The facility Census and Condition Form, dated 5/16/23, documents 99 residents reside at the facility. 1. R86's facility admission Record, with a print date of 5/18/23, documents R86 was admitted to the facility on [DATE], with diagnoses that include pressure ulcers, peripheral vascular disease, diabetes, hypertension, weakness, and acquired absence of toes. R86's MDS (Minimum Data Set), dated 3/8/23, documents a BIMS (Brief Interview for Mental Status) score of 12, which indicates a moderate cognitive impairment. [...]
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide dependent residents showers/baths for 4 of 7 (R6, R7, R81, and R86) residents reviewed for activities of daily living in a sample of 48.
- E
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fresh ice water to 4 of 4 residents (R3, R33, R28 and R11) reviewed for hydration in a sample of 48.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights were not restricted for 1 of 1 (R46) residents reviewed for smoking in the sample of 48. This failure resulted in R46 having her smoking privileges suspended for 30 days, which caused R46 to feel as if she were climbing the walls, feeling fidgety, anxious, and cranky. Findings Include: R46's admission Record, with a print date of 5/18/23, documents R46 was admitted to the facility on [DATE], with diagnoses that include end stage renal disease, chronic obstructive pulmonary disease, heart failure, hypertension, major depressive disorder, diabetes, and insomnia. R46's MDS (Minimum Data Set), dated 2/16/23, documents R46 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates R46 is cognitively intact. [...]
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor antibiotic use for 1 of 1 (R78) resident reviewed for Quality of Care in a sample of 48.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and implement recommended supplements to help heal a pressure ulcer for 1 (R18) of 4 residents reviewed for pressure ulcers in a sample of 48. Findings Include: R18's Face Sheet documents R18 is a female resident, with a birthdate of 11/01/1938, and an admission date of 05/20/22. R18's Face Sheet documents diagnoses including: [...]
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent falls for 1 of 9 (R61) residents reviewed for falls in the sample of 48. Findings Include: R61's admission Record, with a print date of 5/18/23, documents R61 was admitted to the facility on [DATE], with diagnoses that include dementia, Alzheimer's disease, anxiety disorder, insomnia, and need for assistance with personal care. R61's MDS (Minimum Data Set), dated 3/16/23, documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R61 has a severe cognitive deficit. R61's current care Plan documents a Focus Area of (R61) is at risk for falls related to: confusion, deconditioning, psychoactive drug use, with interventions that include 3/12/2023 apply non slip pad to w/c (wheelchair). [...]
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on interview, observation, and record review, the facility failed to implement and provide nutritional supplements as recommended for 2 of 2 (R32, R18) residents reviewed for nutritional supplements in a sample of 48.
Fire safety inspections
23 fire safety citations on file: 10 on June 12, 2025, 11 on August 29, 2024, 2 on May 18, 2023.
Every fire safety citation23 citations
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Create arrangements with other facilities to receive patients.
E 25 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 12, 2025 · Corrected (the home has a date of correction)
- E
Provide properly protected cooking facilities.
K 324 · June 12, 2025 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · June 12, 2025 · Corrected (the home has a date of correction)
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 12, 2025 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 12, 2025 · Corrected (the home has a date of correction)
- F
Address subsistence needs for staff and patients.
E 15 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Establish roles under a Waiver declared by secretary.
E 26 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
K 346 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
K 222 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · August 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · August 29, 2024 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · May 18, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · May 18, 2023 · Corrected (the home has a date of correction)